Nokea
After providing medication instructions, the best evidence that the client knows this drug's potential side effects is when the client states it may cause which adverse effect?
- A. Muscle pain
- B. Palpitations
- C. Visual images
- D. Weight loss
Correct Answer: A
Rationale: Atorvastatin (Lipitor) can cause muscle pain (myalgia) as a common side effect, potentially progressing to rhabdomyolysis in severe cases.
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The nurse anticipates that the client will most likely demonstrate which emotional response in relation to the development of heart failure?
- A. Depression
- B. Anxiety
- C. Anger
- D. Stoicism
Correct Answer: B
Rationale: Anxiety is common in CHF due to breathlessness and fear of disease progression.
Which information about the client's use of a patient-controlled analgesia (PCA) pump is most important to communicate to the staff on the next shift?
- A. Name of the client's physician
- B. Purpose for using the pump
- C. Number of doses administered
- D. The client's need for further teaching
Correct Answer: C
Rationale: The number of doses administered is critical for monitoring pain control and preventing overdose.
Which assessment finding should signal the nurse to withhold applying the client's nitroglycerin patch and notify the physician?
- A. The pressure of 99.8°F (37.6°C)
- B. Respiratory rate of 24 breaths/minute at rest
- C. Apical heart rate of 90 beats/minute
- D. Blood pressure of 94/62 mm Hg
Correct Answer: D
Rationale: A blood pressure of 94/62 mm Hg indicates hypotension, a contraindication for nitroglycerin, which can further lower blood pressure.
When obtaining a health history from the client, the nurse would expect to learn that which of the following was the client's earliest symptom?
- A. Anorexia
- B. Dyspnea
- C. Nausea
- D. Headaches
Correct Answer: B
Rationale: Dyspnea is often the earliest symptom of left-sided heart failure due to pulmonary congestion.
Which response by the nurse is most appropriate at this time?
- A. What are your concerns?
- B. Why are you so scared?
- C. Your doctor says you are doing just fine.
- D. You need to concentrate on getting well.
Correct Answer: A
Rationale: Asking about concerns encourages the client to express fears, facilitating emotional support and reducing anxiety.